Project Summary/Abstract Approximately 400,000 smokers survive an Acute Coronary Syndrome (ACS; unstable angina, ST and non-ST elevation myocardial infarction) each year in the US. The occurrence of ACS can be conceptualized as a ?teachable moment,? whereby patients may be more receptive to smoking cessation messages. Continued smoking following ACS is an independent predictor of mortality. Depressed mood post-ACS is also predictive of mortality, and smokers with depressed mood are less likely to abstain from smoking following an ACS hospitalization. Thus, a single, integrated treatment that targets both depressed mood and smoking could be highly effective in reducing post-ACS mortality. Behavioral Activation may be an ideal counseling treatment for this population because it is easy to train, can be delivered by Bachelor's degree level practitioners, and has recently shown promise for enhancing cessation outcomes in smokers with depression. Through extensive pilot work we systematically developed a counseling intervention that integrates gold standard smoking cessation counseling with Behavioral Activation based mood management for post-ACS smokers; Behavioral Activation Treatment for Cardiac Smokers (BAT-CS). The overall aim of the current study is to conduct a fully powered efficacy trial enrolling 324 smokers with ACS and randomizing them to 12 weeks of BAT-CS or control (including full attention match). Both groups will be offered the nicotine patch if medically cleared. Follow-up assessments will be conducted at end-of-treatment and 6, 9, and 12 months after hospital discharge. We will track the occurrence of major adverse cardiac events and all-cause mortality for 18-36 months post-discharge. The primary outcomes will be depressed mood and biochemically validated 7-day point prevalence abstinence. The specific aims of the study are: Aim I: Test the efficacy of BAT-CS vs. control on depressed mood and smoking cessation. Aim II: Test the efficacy of BAT-CS vs. control on cardiac health. Aim III: Explore hypothesized mediators of treatment effects. Aim IV: Explore the temporal interaction of smoking and multiple aspects of mood over 1 year post-ACS. The long-term goal of this line of research is to improve long-term survival rates following ACS.